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    Arterial Blood Gas

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    Thea Dino
    Let's break this down step-by-step: 1) Respiratory component: Expected PC02 = 40 - (Actual PC02 - Desired PC02) x 0.4 = 40 - (34.4 - 40) x 0.4 = 40 - 5.6 x 0.4 = 40 - 2.24 = 37.76 2) Metabolic component: Expected HC03 = 24 - (Actual HC03 - Desired HC03) x 0.2 = 24 - (30.9 - 24) x 0.2 = 24 - 6.9 x 0.2 = 24 - 1.38 = 22.62 3) O2

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    Arterial Blood Gas

    Uploaded by

    Thea Dino
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    Let's break this down step-by-step: 1) Respiratory component: Expected PC02 = 40 - (Actual PC02 - Desired PC02) x 0.4 = 40 - (34.4 - 40) x 0.4 = 40 - 5.6 x 0.4 = 40 - 2.24 = 37.76 2) Metabolic component: Expected HC03 = 24 - (Actual HC03 - Desired HC03) x 0.2 = 24 - (30.9 - 24) x 0.2 = 24 - 6.9 x 0.2 = 24 - 1.38 = 22.62 3) O2

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    Let's break this down step-by-step: 1) Respiratory component: Expected PC02 = 40 - (Actual PC02 - Desired PC02) x 0.4 = 40 - (34.4 - 40) x 0.4 = 40 - 5.6 x 0.4 = 40 - 2.24 = 37.76 2) Metabolic component: Expected HC03 = 24 - (Actual HC03 - Desired HC03) x 0.2 = 24 - (30.9 - 24) x 0.2 = 24 - 6.9 x 0.2 = 24 - 1.38 = 22.62 3) O2

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    96 views66 pages

    Arterial Blood Gas

    Uploaded by

    Thea Dino
    Let's break this down step-by-step: 1) Respiratory component: Expected PC02 = 40 - (Actual PC02 - Desired PC02) x 0.4 = 40 - (34.4 - 40) x 0.4 = 40 - 5.6 x 0.4 = 40 - 2.24 = 37.76 2) Metabolic component: Expected HC03 = 24 - (Actual HC03 - Desired HC03) x 0.2 = 24 - (30.9 - 24) x 0.2 = 24 - 6.9 x 0.2 = 24 - 1.38 = 22.62 3) O2

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    of 66

    ARTERIAL BLOOD GAS

    ABG

     1. Acid-base Balance
     2. Blood oxygenation assessment
    Arterial pH

     Maintained at 7.35-7.45 by
     Intracellular and extracellular buffering
     Respiratory mechanisms
     Renal mechanisms
     Arterial CO2 tension (PaCO2)
     Controlled by the CNS and respiratory system
     Plasma bicarbonate
     Controlled by the kidneys
     By retention or excretion of acid or alkali
    CLINICAL MANIFESTATIONS

     LOW ARTERIAL PH

    - generalized depressive effect


    - drowsiness and lethargy
    - very low pH (<7.1) – coma
    - < 6.8 for any extended period –
    incompatible with life
    CLINICAL MANIFESTATIONS

     HIGH BLOOD pH

    - excitatory to the CNS


    - irritability or tetany
    - serious arrhythmias
    - very high pH = convulsions
    - > 7.8 – incompatible with life
    pH Symptoms
    7.80 Death
    Convulsions
    Arrhythmias
    Irritability
    7.40 Normal
    Drowsiness
    Lethargy
    Coma
    6.80 Death
    PaCO2

     Usual steady state PaCO2 at 40 mmHg


     Under-excretion causes hypercapnia
     Over-excretion produces hypocapnea
     Regulated primarily by neural respiratory factors
    and not by rate of CO2 production
     May be due to compensatory changes in
    response to a primary alteration in the plasma
    HCO3
    HCO3

     24 (22-26)
     Regulated by
     Reabsorption of filtered HCO3
     Formation of titratable acid
     Excretion of ammonia in the urine
     Kidneys filter 4000 mmol per day
     80-90% in the proximal tubule
    Acid-Base Disorders

     Primary respiratory disturbances invoke


    compensatory metabolic responses and vice
    versa in an attempt to drive pH to normal
     The degree of compensation can be predicted
     Any abnormal compensation define a mixed
    acid-base disturbance
    Acid-Base Disorders
    Acid-Base Disorders
    Causes

    Acidosis
    Alkalosis
    NAGMA HAGMA

    • GI Bicarbonate loss Lactic acidosis • Diuretics


    • Renal acidosis Ketoacidosis • Antacids
    • Drug induced Toxins • Volume
    hyperkalemia Renal failure depletion
    MUDPILES • Cushing
    syndrome
    • CAH
    • Bartter syndrome
    • Gitelman
    syndrome
    Acid-Base Disorders
    Acid-Base Disorders
    Causes

    Acidosis Alkalosis

    COPD Anxiety
    Neuromuscular diseases Pneumonia
    Chest wall disorders High altitude
    Obesity/OSA Pregnancy
    CNS depression Sepsis
    Drugs Drugs
    Anion gap

     Measure of unmeasured anions in the blood


     Major anions: Cl- and HCO3
     Others: phosphates, sulfates and proteins
     Major Cation: Na
     Others: Ca, K, Mg
     Anion Gap: unmeasured anions – unmeasured
    cations
     (Na)- (Cl+HCO3)
     8-10 mmol/L
    Compensatory Responses in Simple Acid-Base Disturbances

     Metabolic Acidosis Limit


     PCO2= (1.5 x HCO3) + 8 + 2 10 mmhg
     Metabolic Alkalosis
     Each mEq inc. in HCO3=
     0.5-1.0 mmhg inc in PCO2 55 mmhg
     Acute Respiratory Acidosis
     HCO3 inc by 3-4 mEq/L 30 mmhg
     Acute Respiratory Alkalosis
     HCO3 dec by 2-4 mEq/L 18 mEq/L
     Chronic Respiratory Acidosis
     Each mEq inc in PCO2=
     0.4 meq/L inc in HCO3 45mEq/L
     Chroinc Respiratory Alkalosis
     Each mEq dec in Pco2 =
     0.5 mEq dec in Hco3 12-15mEq/L
    PRIMARY PROBLEM

     RESPIRATORY

    40 – ACTUAL PCO2 X 100


    40

     METABOLIC

    24 – ACTUAL HCO3 X 100


    24
    EXAMPLE 1
     pH - 7.28
     PaCO2 - 60 mmHg
     HCO3 - 22 mEq/L
     Solution:
     Expected HCO3= 24 + (Actual PaCO2 – Desired PaCO2) x 0.1
     24 + (60-40) x 0.1
     24 + 2
     26
     Acute Respiratory acidosis, uncompensated
    if ph is between 7.35-7.45
     24 + (Actual PCO2 – Desired PCO2) x 0.4
     24 + (60-40) x 0.4
     24 + (20 x 0.4)
     24 + 8
     32
     Chronic Respiratory Acidosis, uncompensated
    EXAMPLE 2
     pH - 7.49
     PaCO2 - 32 mmHg
     HCO3 - 26 mEq/L
     Solution:
     Expected HC03 = 24 –(Desired PaCo2 – Actual PaCo2) x 0.2
     24- (40-32) x 0.2
     24- (8 x 0.2)
     24- 1.6
     22.4
     Acute Respiratory Alkalosis, uncompensated
    if ph is between 7.35-7.45
     24- (40-32) x 0.4
     24- (8 x 0.4)
     24- 3.2
     20.8
     Chronic Respiratory Alkalosis, uncompensated
    Example 3
     pH: 7.50
     PaCo2: 36
     Hco3: 32
     Solution:
     Expected PaCo2: Actual HCo3 + 15
     32 + 15
     47 or
     [(Desired PaCo2 – Actual PaCo2) x 0.75] + 40
     [(40-36) x 0.75] + 40
     (4x0.75)+ 40
     3+40
     44
     Uncompensated Metabolic Alkalosis
    Example 4
     pH: 7.10
     PaCo2: 45
     HCo3: 14
     Solution:
     Expected PaCo2: (1.5 x HCO3) + 8
     (1.5 x 14) + 8
     21+8
     29 0r
     Actual HC03 + 15
     14 + 15
     29
     Uncompensated Metabolic Acidosis
    CLASSIFICATION PaO2 (mmHg)
    Hyperoxemia >100
    Normoxemia 80 – 100
    Mild Hypoxemia 60 – 79
    Moderate Hypoxemia 45 – 59
    Severe Hypoxemia < 45
    QUANTIFYING
    PULMONARY
    DYSFUNCTION
    Indices of Oxygenation

    1. pO2
    2. P/F ratio
    3. O2 saturation
    4. aADO2 – difference in O2 in the alveolus and
    the arterial blood (alveolar-arterial O2
    gradient or difference)
    pAO2 = 713 (FiO2) – pCO2
    0.8
    aADO2 = pAO2 – paO2
    Normal ≤ 20
    Oxygenation

    Expected pO2 at room air:


     For age ≤ 60 y.o. = 80-100
     For age > 60 y.o. = 80 - # of years above
    60
    eg. 70 y.o. = 80-10 = 70

    Ideal PO2 for age: 103.5 - 0.42(age)


    Oxygenation

    At Room Air:
    - Compare actual pO2 to expected pO2
    Actual < Expected = HYPOXEMIC
    Actual > Expected = NON-HYPOXEMIC

    On supplemental O2:
    - Expected P/F ratio (pO2/FIO2)
    For age ≤ 60 y.o.: 400-500
    For age > 60 y.o.: 400 – (age above 60 x 5)
    eg. 70 y.o.: 400 – (10 x 5) = 350
    FiO2 per nasal cannula:
    = (O2 in L/min) x 4 + 20
    eg. O2 at 2 lpm = 2 x 4 + 20 = 28%

    Actual P/F ratio:


    P/F = paO2 (actual from ABG)
    FiO2 (expressed in decimal)
    FiO2 Requirement

    Room air = 0.21

    Nasal cannula= # of liters x 4 + 20/100

    Face mask = # LPM x 10 – 20

    ET = # LPM x 10
    OXYGENATION RATIO

    PULMONARY OXYGENATION
    STATUS RATIO
    Normal 400 – 500
    Moderate Pulmonary 200 – 399
    dysfunction
    Substantial Pulmonary < 200
    dysfunction
    4 MECHANISMS

    1. Hypoventilation
    2. Absolute shunting
    3. Relative Shunting (V/Q mismatch)
    4. Diffusion defects
    Hypoventilation

     Quantitate the efficiency of oxygen loading


     Causes: neuromuscular disorders, chest wall
    trauma, CNS depression, anesthesia effect, high
    cervical spine trauma
    Absolute Shunting

     Blood passing from the right side of the heart to


    the left side of the heart without being exposed to
    alveolar oxygen
     Anatomic or capillary in nature
     Does not respond to administration of
    supplemental oxygen
    Capillary Shunting

     Alveolar consolidation (filling with fluid)


     Collapse
     Causes: ARDS, left-sided heart failure, pneumonia,
    atelectasis
     Pulmonary edema – single greatest cause of
    severe, absolute capillary shunting
    Anatomic Shunting

     Congenital cardiovascular abnormalities


     Persistent fetal circulation
    Relative Shunting

     Most common
     V/Q perfusion mismatch
     Perfusion in excess of ventilation
     Good PaO2 response to small increments of
    oxygen therapy
     Uneven distribution of ventilation secondary to
    increased pulmonary secretions
     COPD
    Diffusion defects

     Anatomic impedance to oxygen transfer in the


    lungs, due to a thickened alveolar-capillary
    membrane
     Responds to oxygen therapy
     Can be included to relative shunting
    PHYSIOLOGIC SHUNTING

     Percentage of the venous blood that remains


    unoxygenated after traveling from the right side
    of the heart to the left side of the heart
    I. (alveolar) PAO2 = 713 (FiO2) – pC02/0.8

    II. (arterial) PaO2 = PAO2 (O2 for age/PO2)

    III. FiO2 requirement (minimum)

    PaO2 + pCO2/0.8
    ------------------------ x100
    713
    Exercise

     pH 7.36
     pCO2 46
     HCO3 26
     pO2 154
     FIO2 100%
     Age 42
    Compensated Respiratory Acidosis with
    Hypoxemia with Overcorrected FIO2 at 100%

     Respiratory
    Acidosis (Acute)  Get O2 for Age
    Exp HCO3= 24+ =103.5- (0.42 X
    [(Actual PCO2- age)
    Desired PCO2) X =103.5- (0.42 x 42)
    0.1] =103.5- 17.64
    24+ [(46-40) x 0.1] =85.86
    24 + (6 x 0.1)
    24 + 0.6
    26.6
    Compute for PF=
    Actual/FIO2
    = 154/100
    = 154
    New FIO2

     I = 713 (FIO2) – Pco2/0.8


    = 713 (100) – 46/0.8.
    = 713- 57.5
    =655
     II = I (O2 for age/po2)
    = 655 (85.86/154)
    = 655 x 0.55
    =360.25
     III = II +[( PCO2/0.8) x 100]/713
    =360.25 + (57.5 x 100) / 713
    =41750/713
    58.55
    Exercise:
     Age; 42
    Ph=7.56
    PC02= 34.4
    P02= 156
    HC03= 30.9
    FI02= 40% MV
    Combined Metabolic Alkalosis with underlying
    Respiratory Alkalosis with hypoxemia with
    overcorrected FIO2 at 40% FIO2

     Respiratory  Metabolic
    = 40-PC02x100  =24-HC03x100
    40
     24
    = 40-34.4x100
    40  24-30.9x100
    =5.6x100  24
    40
    =560  -6.9x100
    40  24
    =14  -690
    24
     28.75
     P/F ratio= 156/.40
     =390
     O2 for age= 103.5 – (0.42x42)
     =103.5-17.64
     =85.86
    New FIO2

    I = 713 (.40) – PCO2/.8


    = 285- 43
    = 242
    II = I (O2 for age/PO2)
    = 242 (85.86/156)
    = 242 x .55
    = 133
    III = II [(PCO2/0.8) x 100]/ 713
    = 133 ( 43 x 100) x 100/713
    = 24
    Exercise

     Age: 79
     pH: 7.32
     PCO2: 28
     PO2: 101
     HCO3: 14
     FIO2: 2 lpm via NC
    Metabolic Acidosis, uncompensated,
    non-hypoxemic, with overcorrected
    FIO2 at 2lpm Nc
     Expected PCO2= (1.5 x  O2 for Age
    HCO3) + 8
     103.5 –(0.42 x 79)
     (1.5 x 14) + 8
     103.5 – 33.18
     21+ 8
     70.32
     29
     P/F ratio= 101/.28
     360
     Expected P/F ratio
     400- (19x5)
     400 – 95
     305
    New FIO2

     I = 713 (FIO2)- PCO2/0.8


    =713 (.28) -35
    =1.99.64-35
    = 164
     II =I (O2 for age/PO2)
    = 164 x 0.69
    =113.16
     III = II x [(PCO2/0.8) x 100]/713
    = 113.16 x (35 x 100)/713
    = 20. 77
    Exercise

     Age: 54
     pH: 7.53
     PCO2: 45.2
     HCO3: 37.8
     PO2: 78
     FIO2: 8l FM
    Metabolic Alkalosis, uncompensated
    with hypoxemia, uncorrected @ 8LPM
    via N.C
     Expected PCO2= Actual  PF ratio= 78/0.60
    HCO3 + 15
     130
     37.8 + 15
     O2 for age=103.5-(.42 x
     52.8 or age)
     [(Desired HCO3-Actual  80.82
    HCO3)x0.75] + 40
     10.35 + 40
     50.35
    New FIO2

     I = 713 (FIO2) – PCO2/0.8


    = 713 (.60)- 56.6
    = 427- 56.5
    = 371
     II = I (O2 for age/po2)
    = 371 x 1.03
    = 382
     III = III + [(Pco2/0.8) x 100]/ 713
    = 382 + (56.6 x 100)/ 713
    = 61.5
    Exercise

     Age: 68
     pH: 7.24
     pCO2: 94.1
     pO2: 60
     HCO3: 40.4
     FIO2: 2l NC
    Acute Respiratory Acidosis,
    uncompensated with hypoxemia,
    uncorrected @ 2 lpm via N.C
     Expected HCO3=24+  O2 for age=103.5-
    (Actual HCO3-Desired (0.42xage)
    HCO3)x0.1
     103.5-28.56
     24+ (54.1x 0.1)
     74.94
     29.41
     PF ratio= 60/.28
     214
     PF for age=400-(8x5)
     360
    New FIO2

     I = 713 (FIO2) – PCO2/.08


    = 713 (0.28) – 117.625
    = 82.015
     II = I (O2 for age/PO2)
    = 82.015 (74.94/60)
    = 102
     III = III + [(PCO2/0.8) x 100] /713
    = 102 + (117.625) x 100/ 713
    = 30
    Henderson-Hasselbalch equation: to determine if
    acid is chronic or acute

     A. H+ = 24x PCO2/ HCO3


    = 24 x 94.1/40.4
    = 55.68
     B. Delta H+= [H+] – Desired PCO2
    = 55.68 – 40
    = 15.68
     C. Delta PaCO2= Actual PCO2- Desired PCO2
    = 94.1 - 40
    = 54.1
     D. Delta [H+]/Delta PCO2
    = 15.68/54.1
    = 0.3 = Acute on top of chronic
    Interpretation

     0.3 – 0.7
     < 0.3 chronic hypercapnia
     > 0.7 acute hypercapnia
     0.3 -0.7 acute on top of chronic
    Exercise

     Age: 32
     pH: 7.41
     pCO2: 36.7
     pO2: 56
     HCO3: 23.5
     FIO2: 4l NC
    Normal Acid base balance with
    Hypoxemia uncorrected @ 4l via NC

     O2 for age=103.5-
    (0.24x32)
     PF ratio= 56/0.36
     103.5-13.44
     155
     90.06
    New FIO2

     I = 713 (FIO2) – PCO2/.8


    = 713 (0.36) – 45.875
    = 256.68.-45.875
    = 210.805
     II = I (O2 for age/PO2)
    = 210.805 x 1.6-8
    = 338.97
     III = II [PCO2/0.8 )x 100]/713
    = 338.97 (45.875 x 100)/ 713
    = 53.97
    HCO3 Deficit

     Metabolic acidosis
     18 to 20 (desired)-actual HCO3 x (0.4 to 0.6) x
    weight
     Half of computed is given SIVP then half as 24
    hour drip
     Repeat ABG post correction

     Example:
     pH 7.18
     PCO2 27
     HCO3 9
    Thank you for your attention

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